It’s quite common that a new physician joins your healthcare facility either from another practice or out of residency. It’s the time when you have to deal with many managed-care organizations or MCOs, so your new physician needs to be credentialed.

This process requires a lot of time and effort. First, you have to collect all documents from the provider – from valid state license to hospital privileges to confirmation of malpractice insurance. Then you have to wait at least 30 days (but it usually takes longer) for the MCOs to check and verify documentation before the new physician can be added to the panels. During this time, the physician is not allowed to treat your care patients. At least, the physician will not be reimbursed for treating, which dramatically limits the ability of the physician to create revenue for your facility. At this point, many start asking why this process takes so long. Is there any way to reduce delays? Below you can find some tips to help you and your facility.

Why is this process so long?

There are many reasons for delays, but the main ones are MCO’s desire to match the NCQA (National Committee for Quality Assurance) standards and inefficient planning on the part of practices and physicians.

One of the NCQA standards that are called the Initial Primary Source Verification stipulates that the MCO should verify several documents, like records of professional liability settlements, prior to assigning credentials. When the MCO really wants to meet this standard, they make withhold credentials from a new physician until the very last detail is verified.

Poor planning is also a popular reason for delays. Quite often, new physicians don’t start credentialing process until they arrive at practice, even though they’ve started filling the applications months earlier. And there can be a huge delay since collecting references can take months and then weeks until they arrive. Until all information arrives at the MCO, an application cannot be considered complete – and while it’s not complete, the credentialing process is stalled.

For that reason, many healthcare facilities require submitting application at least 90 days before the physician’s start date. The processing time can take less than 90 days, but it’s a benchmark since it allows extra time when some documents can’t be verified in timely manner or discrepancies is required.

You should just keep in mind that credentialing process will take as long as needed to collect all information, receive board recommendation and verify all sources. It’s hard to estimate the minimum or maximum frame for the credentialing or privileging process, which both may take longer than three months. Medical staff bylaws, which define privileging and credentialing processes, specify that applications must be acted upon a certain period of time. Some credentialing applications may be finished faster than others, and it always takes longer if the primary source can’t be verified, if a physician omitted information or made mistakes on the application, or if there are red flags that require careful investigation.

While we all hope that our doctors have the highest qualifications, there are cases when patients suffer inappropriate care. At many hospitals across the country, where quality care is their biggest concern, medical staff always struggle with the task of properly privileging their physicians.

There are at least two reasons for this. The first one is medical board requirements and rules that vary in each state, making it quite difficult to hire physicians from different states and develop credentialing standards. The second one is that appropriate privileging training has sometimes been inefficient, mainly due to the lack of appropriate healthcare facility’s resources and personnel.

However, hospitals still stick to the privileging process and try to make it as easy and quick as possible. Below there are the main reasons for granting privileges, and how to make this process more pleasant.

Understand the importance of the process

Every healthcare facility should understand that no provider can be allowed to provide services until he/she has successfully met the requirements of a privileging process and proved the competence and experience. Hospitals should begin by collecting applications that have all necessary information (for example, certification and training). Then this information should be verified through reliable sources to ensure that this physician data is valid.

Complacency cannot lead the privileging process

The very first goal of any reliable healthcare provider is to deliver the highest quality patient care, thus hospitals have to go through all necessary steps to develop a perfect and clear privileging process and reevaluate and update the process to ensure the best results. Evaluating new physicians and assigning proper privileges can take a lot of time even under the best circumstances. The better your process is, the sooner you’ll grant privileges to a physician, thus the sooner he/she will start treating patients and brings you more revenue.

Look outside the box

When you’re evaluating credentials applications and files, having everything done properly and get all the documents is quite important, but it is not a guarantee of success. Sometimes physicians don’t include information that is as important as data that is included, and it can require a well-trained credentialing expert to get rid of useless information and find important nuances in physician’s life and practice.

Appropriately trained credentialing specialist is recommended

Lack of privileging success is quite often due to incomplete, insufficient, or improper resources and personnel. Unfortunately, erroneous or incomplete decisions based on fake information (which results in granting privileges to an incompetent provider) can compromise the quality of patient care. It’s really important that a hospital takes all appropriate steps and has the most highly trained staff.

Explain to your staff the importance of privileging process

It’s vital that your committee members, physician leaders, board members and senior management understand the importance of privileging. Obtaining their support will kick off the whole process on the right foot and dramatically improve chances for success. For healthcare providers that provide honest information and meet the standards, the result of the process is predictable. And when you get a perfect physician, he/she assures the highest quality care possible.

Hospitals and other health care facilities are required to verify the qualification of those who provide services to their patients. In order to ensure patients receive safe and quality care, physicians have to undergo a process, which is called a credentialing. Credentialing process means a practice by which healthcare facilities verify skills and qualifications of their providers to ensure each patient that they possess necessary skills to provide services to patients. Once a physician is credentialed, hospitals have to further investigate practitioner’s competence in a concrete area of care, through a process that’s called privileging.

The main principle of the credentialing is the responsibility of hospitals for ensuring quality care for each patient. In multiple efforts to reach this aim, healthcare facilities take numerous steps to verify proficiency of their providers through the collection and evaluation of information relevant to the professional performance of the practitioner. These two processes happen after a physician has already met licensure requirements.

In the vast majority of hospitals and healthcare facilities, physician credentialing has two stages. During the first one the hospital checks that the physician has completed education and training, can practice in the state where health care is being administrated, and does not have violations and malpractice issues on record.

Applicant identification is one of the first things a physician has to go through. The application requires a copy of an ID with a photograph. It’s also recommended to send a copy of the picture when a healthcare facility requires references from the applicant. This would prove that the applicant didn’t use an ID and a photo of another provider. Moreover, in many states it’s mandatory to perform a thorough background check on all physicians. This background check differs from verification of provider’s data. Many healthcare organizations even hire a third party to provide a comprehensive investigation of court records – both civil and criminal – at the state and federal level.

Hospitals have to collect a lot of information regarding each physician’s licensure status, experience, training, ability to perform privileges and competency. Verifying that all providers meet the standards and that there are no questions about their behavior, credentials, references, education and training help filter out troublesome or incompetent candidates. The hospital’s bylaws should develop a process for approval and review of all applications and reapplications. All credentialing, privileging and re-credentialing recommendations and decisions have to be documented and approved by the governing board.

Moreover, there are healthcare facilities that require their providers to undergo another credentialing process, which is known as periodic credentialing. This process allows hospitals to double-check the qualification of their physicians. During this process, hospitals have another opportunity to verify one more time the competency of their providers.

After the credentialing process is done, the hospital gives the physician a permission to deliver services in the healthcare facility, be it cardiology, surgery or anything else. Once the hospital is sure that a physician’s competence in his field of practice is real, the physician gets credentials and privileges.

It’s a proven fact that in order to predict somebody’s future behavior one should examine the past behavior of that person. Thus, the best way to hire the most professional physician is by examining his/her background and work history. Below you can find the key components of the successful credentialing process.

Ask about any malpractice issues

Every hospital can create its own application form, and yours should ask detailed information about formal warnings or reprimands, or if the applicant has ever been put on probation. You should clearly explain that omission of any important information in the application can be a reason for an immediate loss of credentials and privileges. You should require the National Practitioner data Bank and review the results searching for evidence of professional misconduct. New recruits should be asked about their professional knowledge and references. If the recruit has references stating anything but good professional behavior, he/she should get in contact with medical staff leader for an explanation. And also a little note about references: always ask new recruits for references that can shed light on the professional conduct of the new provider. If the credentials committee thinks there have been issues with unprofessional behavior, they will contact individuals who could have direct knowledge of the misconduct. It’s the applicant responsibility to provide you with honest references and until they are returned, credentialing process is not complete. And if former medical staff representatives or hospital personnel are reluctant to speak about behavioral concerns regarding a physician applying for credentials, ask the physician to provide a specific release stating that he will not bring legal actions if those individuals are forthcoming with information.

Interview potential providers

Interviews are a great way to reveal some behavioral or personality problems. For example, you can ask a physician how he would respond if a nurse observes inappropriate physician conduct in the facility. If the applicant can’t acknowledge inappropriate conduct of the physician or won’t report it to the hospital leaders, consider it as a red flag. Moreover, those who show immaturity, defensiveness or self-centeredness are prone to unprofessional behavior more than others.

Credential committees can sometimes dismiss red flags on the ground that they’re unsubstantiated because they simply can’t find information about the applicant’s past. As a result, you may end up hiring a problematic physician. However, good credential committees always ask applicants to provide additional references to help deal with concerns. For example, if there are rumors that the applicant has been disruptive elsewhere, the committee can require more letters of reference or interview the director of the previous hospital about the performance of the applicant. Credentials committees can also ask questions, like has this physician ever been disciplined for unprofessional conduct? Has he been the subject of an investigation? The credential committee should know applicant’s past experience so they can ask complicated questions while processing the application. They can even ask the applicant to undergo a special evaluation. There are multiple organizations that analyze behavioral problems in applicants.

Getting hospital privileges is a complicated, time-consuming process. However, once a physician gets the privileges, he/she should renew them at least once in two years. In the past, it was done automatically, as long as a physician shows high performance and meets all standards. However, since 2008 hospitals are required to develop their own criteria to renew granted privileges based on different standards, such as patient satisfaction rate, mortality rate, complication rate, and even handwriting legibility. So, keeping privileges is quite a chore for physicians, and the only way to make it a bit easier is to get you acquainted with all steps.

Two parts of hospital privileges re-approval process

Re-application for privileges consists of two parts – re-credentialing process and new privileges determination. Re-credentialing process is held to check one more time if the physician still has skills and qualification to retain his/her privileges. The hospital staff performs another background check, evaluates the physician’s performance throughout the year, and verifies training and education. Then you will be given your privileges again, which will allow you to do certain things in the hospital. Sometimes, a hospital allows you to retain all your privileges. However, they can also give your very limited privileges, restricting you to perform only one function or procedure. Or they can grant you with broader privileges, and you’ll be able to do almost everything in your specialty, including consult, admitting patients, performing multiple procedures and so on. Moreover, more and more hospitals get associated with a particular practice. And if you don’t belong to that practice, your privileges may be reduced or you’ll get no privileges at all. That’s the modern world of medical politics.

Basically, there are four steps you should go through:

• Contact the office of your hospital and get their application form
• Fill and submit everything properly and return it back
• Follow up to make sure everything goes smoothly and medical staff has everything they need
• Prior to the privileging meeting make sure you send all recommendations and letters of references

In some hospitals, there are also different types of privileges. Sometimes, you can even choose what is best suited for your practice. Courtesy privileges mean that a physician can admit only a number of patients. It’s still enough for medical insurance companies to grant privileges to a physician. In this case, physicians usually don’t attend medical staff meetings. These privileges can suit those physicians who don’t expect to do procedures or admit patients at the hospital.

Full privileges mean that physicians can admit unlimited number of patients and should perform core procedures of the medical specialty. Physicians also have to attend medical staff meetings regularly.

The vast majority of medical insurance companies require physicians to hold privileges to be allowed to be part of any medical network. Obtaining the privileges isn’t the easiest task, but it will prove you can provide quality health care. So, many hospitals help physicians to get their privileges.

All patients want good, skillful, qualified doctors. Naturally, hospitals want the same. That means that being a licensed physician is not enough to get hospital privileges. Hospital privileges can be called prescriptions that allow physicians to perform a certain set of operations and procedures, or even admit patients. As hospital executives say, without privileges, a physician can’t be considered qualified.

There are several regulatory bodies – including Medicare, Department of Health and Senior Services, and Joint Commission on Accreditation of Healthcare Organizations- that hold healthcare facilities responsible for appropriately granting privileges to every physician before he can start practicing in the facility.

Getting hospital privileges is a complicated, tedious, and detailed process. But hospitals have to ensure patients get the best care. Physicians go through the similar process at all hospitals across the country, and each hospital is required to make an independent decision about the individual physician.

Before a physician, or any doctor, can treat patients in the facility, they have to fill out and submit the application asking for permission to practice at the hospital. They also have to obtain a permission to carry out certain procedures and treat patients at the hospital.

All of the physician’s credentials – residences, education, training, experience, and fellowships – are carefully reviewed for appropriateness of competency and training. Most of the time, applications are verified by medical staff services and also reviewed by the leading physicians of the hospital.

Medical department’s chairman and Credentials Committee set recommendations about special privileges and appointment to the staff. Then, their recommendations are reviewed by the Medical Executive Committee, and their results are sent to the Board of Trustees, which decide whether they approve the application or not.

If a physician meets all the guidelines and requirements, then he’s granted privileges that he appear to be properly trained to carry out. Physicians can even obtain privileges to work in several hospitals, but the majority chooses to stay in one facility. However, privileges can be denied if the hospital decides a physician doesn’t have a proper training or doesn’t demonstrate competency. Besides, exclusion from Medicaid or Medicare, loss of medical license, or having found of abuse or frauds are reasons for withdrawal of hospital privileges. Privileges can also be suspended when a physician doesn’t treat enough of patients to stay proficient or doesn’t perform enough of procedures.

Physicians should state which specialty they want to practice, and all materials are sent to the chosen specialty. Then physician committee evaluates the application and makes the suggestion. However, the board decides whether or not grant privileges to the physician. If an employment contract allows, a physician can join more than one medical staff. Most often, a physician is needed at many hospitals when the specialty is narrow. It also helps to build the patient base and maintain professional skills.

Hospitals privileges are also required by many insurance companies that won’t allow participating as a provider in the provider panels otherwise. For hospitals, it’s also beneficial to grant privileges. It allows them to treat certain patients, improve medical equipment and generate revenue.

Credentialing process means deciding whether a physician is skillful enough to perform services he wants to perform. This requires a lot of paperwork and can be done differently by different healthcare facilities. Once a physician gets credentials, he can apply for privileges, or the ability to perform specific procedures and treat specific conditions. This is done at each hospital and requires close examination of physician’s application.

There are different ways to do the privileging process. The most traditional one is to create a list of all treatments and procedures. Applicants check if the hospital has procedures they wish to do. Then applicants have to prove that they have knowledge and qualifications to perform the desired procedures. Once applicants show that they can perform the procedures, medical staff searches for any subjects to supervision and decides whether to reject the privileges or not. This way of granting privileges allows medical staff to provide recommendations to the board about the applicant. Applicants can request only those privileges they really need and provide documents only for the data that look suspicious to the medical staff.

However, there is one potential problem – sometimes applicants simply forget to mark the procedure. As a result, they’re not allowed to perform it. Besides, medical staff is required to check the competency of the physician to perform requested treatments and procedures. And, for example, if the surgeon wants to perform a procedure, he/she will have to check not only surgeon boxes, but OB/GYN and pediatric boxes as well.

Another way is core privileging. In this case, applicants pick one of the predetermined groups of treatments or procedures that are the most common to that specialty. However, medical staff has to include or exclude all procedures in core privilege list.

Whether method you would like to use, applicants have to show their experience, training, education and competence for the privileges they want to get. You should develop a predetermined criteria or standards and then verify applicant’s skills against the standards. These criteria should apply to only one procedure or specialty, and not to the whole department. Your standards should be fair, equal for everybody and related to quality health care.

In order to verify education and training you should look at the background of the new recruit. Board certification is also a good criteria, but it should not be the only one in granting privileges.

Current competence can be determined by examining letters of reference which usually include information on the recruit’s performance and improvements. Competition may also include examining the number of procedures performed, or patients treated. However, many skills cross over between different procedures, so the number of them may not show real skills of an individual.

After developing new privileging standards, a hospital should send them to a medical executive committee for the approval. The committee will review the standards and make sure they are fair. Then, the final draft is sent to the board. Once they are approved, medical staff has to follow them.

Credential process has always been an integral part of the process of practicing medicine. For anyone who wants to treat patients, it’s essential to have a document that proves they are allowed to do so. Yes, it is as simple as that. Credentialing is something that has been going hand in hand with medicine for many years.

There were times when doctors could simply treat first three patients, get a proper certificate and start practicing. Today, credential process is long and time-consuming and can cause headaches if not managed properly. Whether you’re a physician opening a practice or just adding a new doctor to a team, you should start the credential process in advance – sometimes even nine months before you’re going to see your first patients. If you’re not in the plan, you can’t work with patients. If you want to earn money, you have to be credentialed. And to get credentialed without problems, you should continue reading the article.

Get All The Papers Together In Advance
Start organizing everything far in advance. Mobilize your staff as soon as you find out the new physician is coming – or, if you’re a solo physician, as soon as you decide where you’re going to set up practice. Most of the time, you will need a proof of malpractice insurance and a license before you get all hospital privileges. And you need hospital privileges before you get credentialed by the plans. Note that many hospital committees meet quarterly, so you have to complete all paperwork well ahead of time.

As MD of Bakersfield Orthopedic Medical Group Alfred Coppola states, their manager started managed-care and hospital plans credential process well in advance, so that their new spine surgeon had a full appointment schedule on the same day he started seeing his patients.

Keep Track Of Your Documents
Managed-care plans are well-known for accidentally losing physician documents, applications and other stuff. It is strongly suggested to mail your documents as “return receipt requested”. This way, you can at least prove that your application was received. Besides, somebody will have to review your application before sending it. Note that if you leave something blank, you paper can be put to the bottom of the big pile.

If you have some problems, speaking to a manager would be better than speaking to a front-line employee. If you spend some time building relationships with an authority, chances your document will get lost are lessened. It always helps when managers can put your face with your name. If your documents get lost, don’t panic – consistent follow-up will help you find them. Call them regularly and ask the same person all the time. They will remember your name and your problem.

Don’t think there are unimportant details – submitting incomplete information or leaving blank fields will cause delays as payers don’t work on any application until you provide them all information they ask for. Note that a common application misses information in four main areas: malpractice insurance, current work status and work history (don’t forget the physician’s start date), covering attestations and hospital privileges. Besides, payers always have a deeper look at those who have gaps in service that are longer than a month. Provide all possible explanations in your application, so that nobody will have a reason to require additional details.

Don’t be shy and look out for peers. An important part of the credentialing process for any physician is to serve as references for colleagues. If somebody asks you, provide turnaround as quickly as possible to avoid delays. Look out for other physicians and help fellow workers to finish the process.

Check your application multiple times to see if you get all the information right. If you submit everything properly, you will get credentialed within 90 days. And if you make a mistake, you will not be able to work with patients.

Whatever you’re going to do, never try to modify any documents – be it letters from committees, letters of reference or any other paper. It can be quite tempting, but don’t go for it. Chances that you will be caught are extremely high.

Be aware that the physician credentialing process is always frustrating and lengthy. Keep that in mind and don’t act impatient or defensive toward the staff you’re going to meet. Wait times often can’t be controlled by credentialing staff anyway.
Finally, be thorough with your papers. It requires a lot of time at the beginning, but it will save even more time later.

Just recently there have been some interesting changes in legislation concerning health care. New regulations require behavioral health programs to upgrade the standards of credentialing and provide the credentialing process differently.

Before you start worrying how your team is going to handle even more credentialing work, let’s have a look at these changes and consider it as an opportunity to improve your administrative process.

Now, there are Health and Recovery Plans available for people who need significant mental support. To be able to administrate HARPs, a hospital has to increase credentialing requirements and ensure the program has:
• Adequate network
• A process that can handle the new credentialing process
• Experienced staff
• A compliant credentialing process

There is going to be a data management platform that allows hospitals to manage and maintain information about the credentialing process. The main thing you should do to meet the requirements is to constantly update data on the platform. Specifically, answer the following questions to maintain adequacy requirements:
• Is the hospital accessible to the clients?
• Are your providers able to meet the needs of patients?
• Can your patients understand what your providers tell them?

There is a simple solution that helps hospitals meet new credentialing requirements: new software. There are software systems that help handle data collected during credentialing processes. Usually, one system is enough to manage all paperwork. Note that this software can cost quite a lot and may not have a user-friendly interface. However, nowadays almost every person is technologically savvy and can quickly get acquainted with new software. Moreover, modern software is easier to manage and has improved interface.

The credentialing process serves both patients and providers, and physicians have the right to expect recognition of their efforts, so they need to provide relevant information that reflects what they really do in practice. Lots of feedback has been provided concerning unnecessary difficulties during the process, so we can expect further changes that will make everything a lot easier. For now, there are still lots of costly applications and time-consuming processes that physicians have to go through every 2 years.

Every physician knows two questions patients ask – “Have you done this to somebody else?” and “How does the hospital let doctors practice in the facility?” These are understandable and straightforward questions. At the end, we constantly check our all service providers at sites like Angie’s Kist or Better Business Bureau. And still, the medical profession and the way its self-policing is shrouded is still a mystery.

One of the main secrets almost all states’ health law has is that there is a “corporate practice of medicine” doctrine. It says that hospitals can’t employ doctors at all. Confused? It simply means that hospitals can’t practice medicine, only doctors can. Never mind that many hospitals advertise they have the best and the most professional doctors in the field. Hospitals can employ administrators, technical personnel and nurses. Doctors, on the contrary, are independent contractors and not hospital employees. That’s why when a patient is accidentally injured because of medical errors, the people in the hospital point their fingers at doctors and remind that doctors don’t work in hospitals.

But these independent contractor doctors can somehow come to work in hospitals. How? That’s the second important secret of the health law – physician credentialing. Credentialing refers to a process that hospitals use to decide whether or not they should let a doctor practice medicine at their facility, including the list of activities that the doctor can perform there. As a simple example, a neurosurgeon may have staff privileges at a certain hospital to perform brain surgery, but not allowed to do other surgeries.

Getting an official permission is a long process, but once a doctor has credentials to work at the hospital, he has to provide the health care that will be reviewed by hospital committees. That is another secret of the law: peer review means a process during which doctor’s colleagues discuss and evaluate his performance. It’s needed to decide whether the doctor’s care is safe. Whether it meets the latest standards of what a professional would do. It sounds quite good and every patient would think this information is useful and comprehensive and would count on it when selecting a doctor. However, health law allows keeping this information confidential and hidden from the public.

As it was stated by the Houston’s Fourteenth Court of Appeals, this confidentiality privilege enjoyed by doctors and hospitals hides all records and proceedings of credentialing documents and keeps them in the complete secrecy. And that is true for many states, which keep confidential all records and proceedings of peer review committee, and communications within the committee are privileged.

Therefore, each time a patient meets a doctor, he has to take a big leap of hope that this particular hospital takes credential process and peer review process seriously. Families and patients can’t demand any documentation to review the past outcomes of doctors or whether the doctor had issues with patient safety in the past. In reality, public may find out about incompetent specialists only when numerous unexpected, bad outcomes are publicized through media and lawsuits.

So, when an accident happens, is a hospital responsible for anything at all? Can the hospital be responsible for credentialing a poor specialist, or for letting the incompetent doctor to work and practice medicine at that hospital?

Instead of a negligence standard used in many other cases, when a victim tries to sue a hospital for improper peer review or credentialing of a doctor, health law requires “malice”. To put it simply, a patient has to plead and prove that was the hospital, which maliciously allowed that doctor to practice in the facility. And if you think that a reasonable hospital will obviously fire the incompetent doctor, you’re wrong.

It’s pretty difficult to prove the standard of malice. At the very least, you have to prove that the hospital had a specific intent to cause an injury to the patient. Another option is to prove that it was an omission that involved a certain degree of risk and the hospital was aware of it, but still chose to allow the doctor to practice in the facility with indifference to the safety, welfare and rights of the patient.

So, what can you do to get actual information about your doctor in the secretive environment of health care?

Almost every state has a Medical Board website, which contains profiles of the vast majority of doctors. Besides, when you get to the doctor’s office, don’t be shy and ask questions.

When you’re seeing the doctor, ask him about his medical school, about the residency, whether or not he is board certified and how long he’s been practicing in this field.

When a doctor prescribes a drug or procedure, ask about possible side effects, risks and benefits of the treatment, and also ask about any alternative treatments, their risks and benefits. You should also ask about how long a certain treatment has been around, and how long the doctor is practicing it.

Health law has given a one-sided protection to hospitals and doctors when it comes to the decision-making, but nothing prevents you from asking well-informed questions before going forward for a treatment.